Thomas Green
16 Feb 2017 · Coroner Joanne Kearsley · Manchester (South)
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. referral to adult general psychiatry while inpatient not considered or acted upon
“It was unclear why a referral was made to Adult General Psychiatry whilst Mr [name redacted] remained an inpatient, there was no evidence that this referral was ever considered or actioned.”
2. discharge without psychiatric follow-up or treatment plan for complex PTSD
“when Mr [name redacted] was discharged from hospital there was no psychiatric follow-up and no treatment plan in place to address the diagnosis of complex PTSD. 3”
3. inappropriate referral to Healthy Minds for complex PTSD case
“The Court heard evidence how this was not a case which was suitable for Healthy Minds as it was complex and involved potentially complex PTSD.”
4. inadequate GP referral failing to convey complexity
“The Court heard evidence that the referral document completed by the GP was not particularly detailed and therefore the complexity of the case was not apparent and the case was accepted.”
5. lack of commissioned services for complex PTSD
“The Court heard evidence that there is a commissioning gap for the provision of services for Complex PTSD and complex presentations such as that of Mr [name redacted].”
Linked reports
Closely relatedConfidence 0.80 · moderate
This report
“When a referral was made this was made to Healthy Minds. The Court heard evidence how this was not a case which was suitable for Healthy Minds as it was complex and involved potentially complex PTSD.”
Later report
“Similarly, patients cannot access a qualified Psychologist whilst under the care of the Home Treatment Team (HTT') etc. The only way for patients to get access to a Psychologist is through referral to 'Healthy Minds'. Health Minds cannot provide access where the patient remains under the care of the HTT etc.”
Closely relatedConfidence 0.90 · high
This report
“The Court heard evidence that the referral document completed by the GP was not particularly detailed and therefore the complexity of the case was not apparent and the case was accepted.”
Later report
“The form completed by the 136 suite team was sent to the GP with the box refer to GP ticked. After receipt by the GP practice there was an assumption that any necessary referral had already been made and no referral was discussed or made.”
Responses
2017-0057-Response-by-Tameside-and-Glossop-CCG-NHS-Trust.pdf ↗· Tameside and Glossop Clinical Commissioning Group
Stated action · 1/6/17
“The CCG will clarify the Individual Funding Request process to ensure that, where required, Pennine Care staff can apply for individual funding for extraordinary care, e.g. for Complex PTSD and ensure that PC.FT staff are fully briefed about the process by 1/6/17.”
Stated action · four months
“The CCG will work with PCFT and GPs to review and establish clear pathways into MH support for people with complex needs. This will identify any gaps which will be taken forward within commissioning intentions. We have commenced this work already and aim to conclude it within four months.”
Stated action
“The CCG will also seek assurance from PCFT that they deliver their action plan regarding this serious incident through our bi-monthly contract monitoring meeting.”